Methods for percutaneously extending an existing spinal construct

ABSTRACT

Apparatus and devices for percutaneously extending an existing spinal construct ipsilaterally with an additional spinal construct in a patient are disclosed. The additional spinal construct comprises a rod connector that includes an elongate additional rod integrally attached thereto. The additional rod is placed through an access port in a first orientation generally parallel to the longitudinal axis of the access port and rotated to a different second orientation generally transverse to the longitudinal axis of the access port. During such rotation the additional rod is moved subcutaneously beneath the skin of the patient from the existing spinal rod to an additional bone engaging implant. In another arrangement, the extension of an existing spinal construct in a minimally invasive procedure comprises a rod connector having an offset support for receiving an additional spinal rod that may be placed laterally interiorly or exteriorly of the existing spinal construct.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.15/204,196, filed Jul. 7, 2016, now U.S. Pat. No. 9,642,655, which is acontinuation of U.S. application Ser. No. 14/872,287, filed Oct. 1,2015, now U.S. Pat. No. 9,629,668, which is a continuation of U.S.application Ser. No. 14/013,234, filed Aug. 29, 2013, now U.S. Pat. No.9,149,302, which is a divisional application of U.S. application Ser.No. 13/617,312, filed Sep. 14, 2012, now U.S. Pat. No. 8,523,906, whichclaims the benefit of U.S. Provisional Application No. 61/568,199, filedon Dec. 8, 2011, the entire contents of these applications beingincorporated by reference herein.

BACKGROUND

The present disclosure contemplates devices and instrumentation forextending an existing spinal construct, and more particularly toprocedures for achieving such extension minimally invasively, andpreferably percutaneously.

An emerging trend in spinal fixation is an increased incidence ofadjacent disc degeneration subsequent to a previous fixation or fusion.This subsequent degeneration often requires fixation or fusion ofadditional levels of the spine. It is common in current techniques toexpose the entire prior construct to access all of the existing bonefasteners to permit removal of the connecting member spanning thefasteners. The connecting member is removed and replaced with a longermember, such as a rod, to engage an additional bone fastener added atthe new levels to be instrumented.

This exposure of the prior fixation construct disrupts the existingconstruct complicating and lengthening the surgical procedure for addingthe additional level of fixation. Such techniques are particularlyproblematic for a fixation construct spanning three or more vertebrallevels. As such, there is a need for a device and method thatfacilitates the addition of further levels of fixation.

Several recent advancements have been disclosed that describe theextension of existing spinal constructs with minimal disruption to theexisting construct. One example is shown in co-pending commonly assignedU.S. application Ser. No. 12/797,682, entitled “Devices and Methods forAdding an Additional Level of Fixation to an Existing Construct”, filedon Jun. 10, 2010 and published as No. 2010/0318131. Other examplesinclude U.S. Pat. No. 7,976,567, entitled “Orthopedic RevisionConnector”, issued on Jul. 12, 2011 to William B. Null, et al. and U.S.Pat. No. 8,021,399, entitled “Rod Extension for Extending FusionConstruct”, issued on Sep. 20, 2011 to Stephen Ritland. While theseapproaches represent improvements in revision techniques and devices, itwould be advantageous to not only extend an existing construct in arelatively non-disruptive manner to such construct, but to do so in aminimally invasively and, preferably percutaneous procedure.

SUMMARY

It is an object of the present invention to provide apparatus anddevices for adding an additional construct to an existing spinalconstruct in a patient preferably minimally invasively and morepreferably, percutaneously.

DESCRIPTION OF THE FIGURES

FIG. 1 is a side elevation view of a portion of a patient's spineshowing instrumentation disclosed herein to extend an existingipsilateral spinal construct.

FIG. 2 is an enlarged perspective view of the existing spinal constructand inline extension of FIG. 1.

FIG. 3 is a top plan view of the existing spinal construct and inlineextension of FIG. 1.

FIG. 4 is a top perspective view of a rod connector in accordance withone arrangement of the disclosure for attachment to an existing spinalrod of the existing spinal construct shown in FIG. 1.

FIG. 5 is an exploded top perspective view of the rod connector of FIG.4.

FIG. 6 is a longitudinal cross sectional view of the rod connector ofFIG. 5.

FIG. 7 is a view of the rod connector of FIG. 6 showing the hook portionhaving been articulated to a different angular position.

FIG. 8 is a further top perspective view of the rod connector of FIG. 4showing the rod connector in an inline engagement with an existingspinal rod.

FIG. 9 is a top perspective exploded view of a rod connector extensionassembly comprising a rod connector introducer and the rod connector ofFIG. 4.

FIG. 10 is an enlarged side elevation view of the rod connectorextension assembly of FIG. 9 showing details of the distal portion ofthe rod connector introducer positioned for releasable attachment to therod connector.

FIG. 10a is a cross sectional view of FIG. 10 as seen along viewinglines X-X of FIG. 10.

FIG. 11 is a perspective view showing the assembled rod connectorextension assembly of FIG. 9 with an inner sleeve positioned forinsertion into the rod connector introducer.

FIG. 12 is a further perspective view of the assembled rod connectorextension assembly of FIG. 1l with the inner sleeve received within therod connector introducer and a hook rotator positioned for insertioninto the inner sleeve.

FIG. 12a is an enlarged view of the distal end of the hook rotator asencircled in FIG. 12.

FIG. 13 is a top perspective view of a portion of a patient's spine asviewed in the caudal direction showing the assembled rod connectorextension assembly of FIG. 12 disposed within an access port.

FIG. 14 is a top perspective view of FIG. 13 as viewed in the cephaladdirection.

FIG. 15 is a side elevation view of a patient's spine showinginstrumentation for targeting the position of an existing spinalconstruct within a patient and an additional spinal implant extensionassembly spaced therefrom.

FIG. 16 is a further view of FIG. 15 showing dilating instrumentsincluding an access port for use in a percutaneous procedure forextending an existing spinal construct.

FIG. 17 is a further view of FIG. 16 with the dilating instrumentsremoved and the access port positioned within the patient's spineadjacent the existing spinal construct.

FIG. 18 is a side elevation view of the rod connector extension assemblypositioned in the access port with the elongate additional rod of therod connector being oriented in a first position generally parallel tothe longitudinal axis of the access port.

FIG. 19 is a further view of FIG. 18 showing the rotation of the rodconnector introducer and the rod connector with the elongate additionalrod being moved subcutaneously toward the additional spinal implantextension assembly.

FIG. 20 is a further view of FIG. 19 showing further rotation of the rodconnector introducer with the additional rod of the rod connector beingintroduced into a slot of the additional spinal implant extensionassembly.

FIG. 21 is a further view of FIG. 20 showing final rotation of the rodconnector introducer with the additional rod of the rod connector havingbeen moved to a second different orientation transverse to thelongitudinal axis of the access port and the distal portion of theadditional rod extending through slots in the additional spinal implantextension assembly.

FIG. 22 is a view of FIG. 21 with the hook rotator and inner sleevehaving been removed from the rod connector introducer and a driverinstrument positioned to introduce a set screw through the additionalspinal implant extension assembly for securing the additional rod of therod connector to the additional spinal implant.

FIG. 23 is a view of FIG. 22 with the driver instrument removed and adriver tool positioned to introduce a set screw through the rodconnector introducer for securing the rod connector to the existingspinal rod.

FIG. 24 is a posterior view of a portion of the patient's spine showingan additional construct extending an existing spinal construct to afurther bony segment, such as the ilium.

FIG. 25 is a top perspective view of a first alternative arrangement ofa rod connector for attachment to an existing spinal rod of an existingspinal construct of FIG. 1.

FIG. 26 is a further view of the first alternative rod connector of FIG.25 showing an offset parallel connection of an additional rod to anexisting spinal rod.

FIG. 27 is a top perspective view of the first alternative rod connectorof FIG. 25 in assembly with a rod connector introducer and an additionalelongate extension.

FIG. 28 is a top perspective view of a portion of a patient's spineshowing an oval access port positioned adjacent an existing spinal rodfor receipt of the rod connector in the assembly shown in FIG. 27.

FIG. 29 a top perspective view of a second alternative arrangement of arod connector for attachment to an existing spinal rod of an existingspinal construct of FIG. 1.

FIG. 30 is a further view of the second alternative rod connector ofFIG. 29 showing an inline connection of an additional rod to an existingspinal rod.

DESCRIPTION OF THE EMBODIMENTS

For the purposes of promoting an understanding of the principles of theinvention, reference will now be made to the embodiments illustrated inthe drawings and described in the following written specification. It isunderstood that no limitation to the scope of the invention is therebyintended. It is further understood that the present invention includesany alterations and modifications to the illustrated embodiments andincludes further applications of the principles of the invention aswould normally occur to one skilled in the art to which this inventionpertains.

Referring to FIGS. 1 and 2, an apparatus 10 is shown for extending anexisting spinal construct 12 by adding an additional spinal construct 14so as to increase the level of spinal fixation in a patient havingpreviously undergone spinal fusion or other spinal surgery. Theapparatus 10 generally comprises a rod connector extension assembly 16,a spinal implant extension assembly 18 and an access port 20. Rodconnector extension assembly 16 includes a rod connector introducer 21and a rod connector 22 comprising an elongate additional spinal rod 24serving as a connecting element, as will be described. Spinal implantextension assembly 18 comprises an additional spinal implant 26 and anelongate extension 28 releasably coupled thereto. As illustrated, theexisting spinal construct 12 as well as the additional spinal construct14 are located ipsilaterly in the spine in this particular arrangement.As will be described in more detail below, rod connector introducer 21comprises an elongate extension 30 releasably attached to the rodconnector 22. Each of extension 28 and access port 20 is sized and oflength to be accessible outside the patient's skin. The patient's skinor fascia is depicted as a phantom line S for illustrative purposesonly, with the understanding that the level of the fascia relative tothe fixation location on the spine will vary from patient to patient.Spinal construct 12 is an existing spinal construct in the sense that ithas been installed prior to the installation of the additional spinalconstruct 14 which means that existing spinal construct 12 may have beenplaced in a previous surgical procedure or may be placed during the samesurgical procedure as, but prior to, additional spinal construct 14.

Turning to FIG. 2, further details of the additional spinal construct 14and the existing spinal construct 12 are described. The existing spinalconstruct 12 comprises at least two previously implanted bone engagingimplants 34 and 36 each of which is engaged respectively to acorresponding vertebra 38 and 40. Implants 34 and 36 are interconnectedby an existing spinal rod 42 extending ipsilaterally therebetween.Existing spinal rod 42 includes an interconnecting portion 42 a betweenimplants 34 and 36 and an extending portion 42 b projecting outwardlybeyond implant 34, although extending portion 42 b may also project inthe opposite direction beyond implant 36. As shown, each of implants 34,36 is a polyaxial pedicle screw having a lower threaded fastener portion44, 46 for threaded engagement respectively in a pedicle of vertebra 38and a pedicle of vertebra 40. Each implant 34, 36 includes a respectiveupper portion defining a yoke 48, 50 each yoke having a respectivethreaded slot 52, 54 for receipt of the existing spinal rod 42 therein.Set screws 55 and 57 respectively secure the existing spinal rod 42 tothe implants 34 and 36.

The additional spinal construct 14 comprises rod connector 22 includingelongate additional spinal rod 24, and a third bone engaging implant,namely additional spinal implant 26. Spinal implant 26, as depicted inFIG. 2, is a polyaxial pedicle screw having a lower threaded portion 56and an upper yoke portion 58 that articulates relative to threadedportion 56. The threaded portion 56 is threadedly engaged to a thirdspinal segment 60 as will be described. As depicted, spinal segment 60is another vertebral body, it being understood that such spinal segmentmay be segment S1 of the sacrum. The upper yoke portion 58 defines anopen ended threaded slot 62 for receipt and support therein of thedistal free end 24 a of additional spinal rod 24 and is fastened to theyoke portion 58 by a set screw 64 or other suitable fastener. Whileadditional spinal implant 26 is described as being a pedicle screw, itshould be appreciated that depending upon the application additionalspinal implant 26 may include other bone engaging implants withfasteners such as hooks, or rod connectors.

Rod connector 22 comprises a lower first portion 66 and an upper secondportion 68 articulatingly attached to the first portion 66. The firstportion 66 is attached to the existing spinal rod 42 as will be furtherdescribed. The second portion 68 includes a connecting portion 70projecting therefrom that in the arrangement described defines theelongate additional rod 24 terminating in distal free end 24 a. Asillustrated in FIGS. 2 and 3 the additional spinal construct 14 isconsidered to be inline with the existing spinal construct 12. In suchan arrangement, the upper second portion 68 of the rod connector 22 ispositioned above and substantially in alignment with the axis of theexisting spinal rod 42. The connecting portion 70 has a first extent 71and a second offset extent defined by additional rod 24 with a jog 72therebetween. Extent 71 is positioned above bone engaging implant 34while the axis of additional spinal rod 24 is aligned generally parallelto and colinear with the axis of the existing spinal rod 42. As such,the existing spinal rod 42 and the additional spinal rod 24 are spacedapproximately the same distance from a mid-line plane through the spineof a patient. It should be appreciated that depending upon the anatomyof the patient the orientation of the additional rod 24 relative to theexisting rod 42 may differ.

Turning now to FIGS. 4-8, further the details of the rod connector 22are described. The lower end of the first portion 66 of rod connector 22comprises a pair of spaced hooks 74 and 76 each of which includes arespective projecting rod engagement member 74 a and 76 a. Hooks 74 and76 are spaced from each other at a distance defining an opening 78 thatallows the existing rod 42 to be received therebetween.

The first portion 66 of the rod connector 22 is attached to the secondportion 68 by ball insert 80 which allows the first portion 66 to rotateand articulate relative to the second portion 68, as will be described.The ball insert 80 comprises a truncated sphere having a first outerspherical surface 82 and a second outer cylindrical surface 84, as shownin FIG. 5. The outer spherical surface 82 has a maximum diameter greaterthan the maximum diameter of the second outer cylindrical surface 84.The second portion 68 has an interior spherical surface 86 as shown inFIGS. 6 and 7 defining a socket for receipt of the spherical surface 82of the ball insert 80. Interior spherical surface of socket 86 has adiameter slightly greater than the maximum diameter of first outerspherical surface 82 of the ball insert 80. The socket 86 has anentrance opening 88 that has a diameter less than the diameter ofinterior spherical surface of socket 86 and slightly greater than themaximum diameter of outer cylindrical surface 84 of the ball insert 80.The ball insert 80 is inserted through socket opening 88 along an axisof the ball insert 80 defined by a longitudinal axis of the outercylindrical surface 84. As such, the ball insert 80 will pass throughthe socket opening 88 and into socket 86. Once therein, ball insert 80is rotated 90° such that the outer spherical surface 82 is in slidingfacing relationship with the interior spherical surface of socket 86. Inthis position, exterior threads 90 on an upper portion of the firstportion 66 are threadably engaged into interior threads 92 of the ballinsert 80. The ball insert 80 may be secured to the threads 90 of thefirst portion 66 to prevent loosening by locking pins 94 which may beinstalled through clearance openings 95 on opposite sides of firstportion 68. The structure and operation of the ball insert 80 relativeto socket 86 are fully described in commonly assigned U.S. applicationSer. No. 11/560,587, entitled “Multi-axial Spinal Fixation System”,filed on Nov. 16, 2006 and issued as U.S. Pat. No. 8,162,990, thedisclosure of which is incorporated herein by reference in its entirety.

As described and as shown in FIGS. 6 and 7, the ball insert 80 and thejoined rod connector first portion 66 can jointly articulate relative tothe second portion 68 about axis 96 defined by the centerline of opening97 having interior threads 98 extending into the second portion 68 incommunication with spherical socket 86. In addition, first portion 66can rotate relative to second portion 68 about an axis of engagement 100defined by the centerline of exterior threads 90 of the first portion66. In FIG. 6 the axis of engagement 100 and axis 96 of the secondportion 68 are linearly aligned, while in FIG. 7, for example, the axisof engagement 100 is disposed at an angle with respect to axis 96 withfirst portion 66 having been articulated relative to second portion 68.In the position shown in FIG. 7, the first portion 66 is in an unlockedposition and may still rotate about axis of engagement 100 so as tocause hooks 74 and 76 to engage existing rod 42, allowing greaterflexibility for the attachment of the rod connector 22 to the existingrod 42.

Referring to FIGS. 5 and 6 a device for rotating the first portion 66relative to the second portion 68 as well as for providing a provisionalretention of the rod connector 22 to an existing rod 42 is described. Arotation element 102 supported by the first portion 66 comprises arotation pin 104, a wave spring 106 and a retention ring 108. Therotation pin 104 comprises a head 104 a having an internal hex socket104 b for receipt of the hook rotator, as will be described. Socket 104b may comprise other suitable socket configurations, such as aconventional Torx configuration. Rotation pin 104 further comprises ashank 104 c having an upper outer hex surface 104 d a distal outercylindrical surface 104 e and a larger intermediate cylindrical surface104 f between surfaces 104 d and 104 e. Surfaces 104 d, 104 e and 104 fmay also include other suitable configurations.

To assemble the rotation element 102 to the rod connector 22, therotation pin 104 is inserted into opening 97 along axis 96 throughthreads 98 and into opening 110 interiorly of threads 90 of firstportion 66. The interior surface 112 of opening 110 comprises acomplementary hex configuration for matable receipt of the hex surface104 d of rotation pin 104. With such hex surfaces in engagement,rotation of the rotation pin 104 will cause rotation of the firstportion 66. Wave spring 106 is placed over intermediate cylindricalsurface 104 f and retention ring 108 is placed over distal cylindricalsurface 104 e. Retention ring 108 is secured to distal cylindricalsurface 104 e by laser welding or other conventional joining techniques.Securement of the retention ring 108 to the rotation pin 104 compressesthe wave spring 106 between the retention ring 108 and an inner surface114 adjacent, and substantially orthogonal, to interior surface 112 ofopening 110 in the first portion 66. As such, rotation element 102 ismovably supported on said first portion 66 by wave spring 106 with thedistal end of the retention ring 108 defining a rod engagement surface108 a normally biased into the opening 78 between the hooks 74 and 76 ofthe first portion 66. Such biased interference of the rod engagementsurface 108 a into opening 78 allows the existing rod 42 to be receivedinto opening 78 and provisionally held by the rod engagement members 74a and 76 a upon rotation of the hooks 74 and 76 under the bias of wavespring 106 as shown in FIG. 8. It should be appreciated that otherspring elements, such as a helical spring, may be used as alternativesto wave spring 106.

While the rod connector 22 is provisionally retained to the existing rod42 by the rod engagement members 74 a and 76 a under the bias of wavespring 106, this position is an unlocked position with rotation element102 serving as a provisional holding element. A device for locking therod connector 22 in a locked position relative to the existing rod 42 isdescribed with further reference to FIGS. 5 and 6. A locking elementsuch as a set screw 116 has exterior threads 116 a for threadablerotational engagement with interior threads 98 extending within thesecond portion 68. The upper proximal end of the set screw 116 comprisesa suitable socket, such as a Torx hexalobe socket 116 b for receipt of asuitable tool for inserting and rotating set screw 116. The lower distalsurface 116 c is configured to engage the upper surface of head 104 a ofrotation pin 104 during rotational insertion. Continued insertion andtightening of the set screw 116 into threads 98 will cause the rodengagement surface 108 a at the lower end of the rotation element 102 toforcibly engage the existing rod 42, effectively relieving the bias ofwave spring 106 to thereby lock the first portion 66 to the existing rod42. The force against the existing rod 42 also causes the first portion66 and thereby the ball insert 80 to move downwardly relative to secondportion 68 forcing the outer spherical surface 82 at the lower half ofball insert 80 tightly against interior spherical surface of socket 86of second portion 68, thereby locking first portion 66 and secondportion 68 securely together.

Referring still to FIGS. 4 through 7 further details of the rodconnector 22 are described. Projecting outwardly from second portion 68is a connecting element 70. In this arrangement, connecting element 70includes first extent 71 and elongated additional rod 24 terminating indistal end 24 a. Connecting element 70 includes a jog 72 between firstextent 71 and additional rod 24 causing the additional rod 24 to beoffset relative to the first extent 71 so as to accommodate spinalanatomy. It should be appreciated that the height of jog 72 may bevaried to provide different offset dimensions between additional rod 24and first extent 71. In some arrangements, jog 72 may be eliminated suchthat first extent 71 is colinear with additional rod 24. In addition,first extent 71 and/or additional rod 24 may be curved so as toaccommodate different spinal anatomical conditions. In the arrangementshown, additional spinal rod 24 defines a longitudinal axis 24 b thatextends transverse to axis 96 of the second portion 68 of rod connector22. In one application, for example, axis 24 b may be disposed at anangle of approximately 90° with respect to axis 96, shown in FIGS. 5 and6. In the arrangement shown, rod connector 22 is formed as a one-piecestructure. Connecting element 70 including elongated additional rod 24may be otherwise integrally attached to second portion 68 by anysuitable fastening means, including without limitation, welding, brazingand screws.

Turning now to FIGS. 9-12, details of the free hand rod connectorintroducer 21 are described. Rod connector introducer 21 comprises anelongate hollow extension 30 and a handle 118 interconnected toextension by an offset bracket 120. Handle 118 may be selectively movedto different angular orientations by releasing and interlockingprojection 122 into multiple grooves 120 a, 120 b and 120 c in bracket120. Three positions are shown, namely 0°, 45° and 90° with handle 118being in the 0° position shown in FIG. 9 and in the 45° position asshown in FIG. 12. Other angular orientations may also be provided.Hollow extension 30 comprises an elongate outer sleeve 124 having aproximal end 124 a and a distal end 124 b with a lumen 124 c extendingfully longitudinally therethrough. Proximal end 124 a is suitablyattached to bracket 120 and distal end 124 b is configured to securereleasably to the second portion 68 of the rod connector 22.

As illustrated in further detail in FIG. 10, the rod connectorsecurement structure at the distal end 124 b of sleeve 124 comprises aprojecting attachment pin 126 and a skirt member 128 disposeddiametrically opposite pin 126. Attachment pin 126 is of generally ovalshaped configuration and comprises a flexible latch 126 a projectingfrom a side surface of pin 126. Skirt member 128 projects axiallydownwardly from distal end 124 b and has a concave inner surfaceconfigured to correspond to the outer curved surface 68 a at one end ofsecond portion 68. Attachment pin 126 is configured to be received in acomplementary oval shaped hole 130 formed in an upper surface of secondportion 68 of rod connector 22 (see FIGS. 7-8) with flexible latch 126 abeing releasably attached to a ledge 130 a formed in a side wall of hole130 in a snap-fit manner as shown in FIG. 10a . With attachment pin 126received in hole 130 and skirt member 128 extending in close proximityaround a portion of curved surface 68 a, the outer sleeve 124 issubstantially prevented from rotating relative to both the secondportion 68 of rod connector 22 and elongate additional rod 24 which isintegral with second portion 68. While attachment pin 126 and skirtmember 128 are effective in releasably securing the outer sleeve 124 tothe rod connector second portion 68, it should be appreciated that otherreleasable securement structure, such as screw threads, may be used.

Referring now to FIG. 11, rod connector introducer 21 is shownpreliminarily attached to rod connector 22. To provide a more secureattachment, an inner elongate hollow sleeve 134 is included. Innersleeve 134 has a proximal end 134 a and a distal end with a lumen 134 cextending fully longitudinally therethrough. Proximal end 134 aterminates in a flange 134 d having a hex surface for engagement with awrench or other suitable tool. Distal end 134 b comprises externalthreads 134 e for threadable attachment with the interior threads 98 inthe second portion 68 of rod connector 22. After outer sleeve 124 ispreliminarily attached to rod connector 22, inner sleeve 134 is insertedthrough lumen 124 c of sleeve 124 with threads 134 e of the inner sleevethreadably engaging threads 98 in the second portion 68 of rod connector22. Continued tightening of inner sleeve 134 causes flange 134 d toengage an upper surface of distal end 124 a of outer sleeve 124 therebycompressing the outer sleeve 124 between flange 134 d and rod connector22 for secure attachment thereto.

With extension 30 suitably releasably secured to rod connector 22, ahook rotator 136 is inserted into the lumen 134 c in the inner sleeve134, as shown in FIG. 12 to complete the rod connector extensionassembly 16. Hook rotator 136 comprises an elongate shaft 136 a having aproximal end 136 b and a distal end 136 c. Proximal end 136 b includes atool attachment surface 136 d having a hex or other suitableconfiguration for engagement with a hand wrench 135 (see FIG. 21).Distal end 136 c comprises an engagement surface 136 e having acomplementary mating configuration, such as hex configuration, forengagement with the socket 104 b of rotation pin 104. As described abovewith reference to FIG. 5 rotation of the rotation pin 104 causesrotation of rod connector first portion 66 and hooks 74 and 76projecting therefrom.

Hook rotator 136 includes at its proximal end a connection portion 136 fand a ring 136 g. Ring 136 g is pinned to connection portion 136 f toprevent relative rotation therebetween but is spring biased to allowaxial translation when ring 136 g is depressed distally. Ring 136 gincludes an internal hex surface that engages the hex surface of thetool attachment surface 136 d when ring 136 g is biased normallyupwardly, thus preventing rotation. When ring 136 g is depresseddistally downwardly by a suitable tool such as by hand wrench 135, theinternal hex surface of ring 136 g disengages from the external hexsurface of tool attachment surface 136 d, thereby allowing rotation ofthe shaft 136 a relative to connection portion 136 f. Such disengagementallows the tool attachment surface 136 d to engage a complementary hexsurface (not shown) within the hand wrench 135 such that rotation of thehand wrench 135 rotates the elongate shaft 136 a. Upon rotation of theshaft 136 a by hand wrench 135 from outside the patient, the firstportion 66 of the rod connector 22 and thereby hooks 74 and 76 are alsorotated in a manner to effect connection of the rod connector 22 toexisting rod 42, as will be described.

As hook rotator 136 is inserted into the lumen 134 c of inner sleeve 134engagement surface 136 e is properly seated within the socket 104 b ofrotation pin 104. If proper seating is not achieved a marker or othersuitable indicator may extend from the proximal end of elongate shaft136 a to inform the surgeon that engagement surface 136 e is notproperly inserted into socket 104 b. The first portion 66 with hooks 74and 76 may be rotated manually until proper seating is achieved. Uponsuch proper seating, connection portion 136 f of hook rotator 136 isreleasably attached to the bracket 120 at bracket portion 120 d by aflexible portion 136 h, as shown in FIG. 12 to hold connection portion136 f fixed relative to extension 30. As such, rotation of elongateshaft 136 a relative to connection portion 136 f also rotates shaft 136a relative to extension 30 and the rod connector 22 attached thereto.With the rod connector extension assembly 16 thus being assembled,longitudinal axis 24 b of the elongate additional rod 24 projectsoutwardly from extension 30 and transverse to axis 96 of the secondconnector portion 68. In the arrangement shown, the angle betweenlongitudinal axis 24 b and axis 96 is substantially 90°. While a 90°angle is suitable, it should be appreciated that other angles may becontemplated.

In a preferred arrangement of rod connector extension assembly 16, hookrotator 136 is formed at its distal tip 136 i as illustrated in FIG. 12ato have a curved configuration defining a ball hex shape. Thus, whilethe complementary mating configuration of engagement surface 136 e isconstructed to engage socket 104 b and substantially prevents rotationunless shaft 136 a is rotated, the ball hex shape will allow somearticulation of the rod connector first portion 66 relative to secondportion 68, as illustrated in FIG. 7, even when engagement surface 136 eis seated within the socket 104 b of rotation pin 104. With the rodconnector first portion 66 being disposed at an angle with respect torod connector second portion 68, first portion 66 may still be rotatedabout axis of engagement 100 by hook rotator 136. It should beunderstood that the distal tip 136 i of rotator hook 136 may also beformed to be relatively flat such that when the complementary matingconfiguration of engagement surface 136 e engages socket 104 b therewill be substantially no articulation of the first portion 66, with suchfirst portion 66 being held generally fixed relative to the rodconnector introducer 21 by the hook rotator 136.

Turning now to FIGS. 13-14, details of the access port 20 are described.Access port 20 comprises an elongate sleeve 20 a having a proximal end20 b and a distal end 20 c for placement into the patient adjacent theexisting spinal construct 12. The access port 20 is of length such thatthe proximal end 20 b projects out from the patient's skin S when thedistal end 20 c is positioned adjacent existing construct 12. Sleeve 20a includes a perimetric sidewall 20 d and a lumen 20 e extendinglengthwise therethrough. Lumen 20 e is sized to receive the rodconnector introducer 21 with the rod connector 22 secured thereto forattachment of the rod connector 22 to the existing spinal rod 42. Sleeve20 a has a slot 20 f extending axially for a length through the sidewall20 d such that the slot 20 f extends outside the patient when the distalend of the access port 20 is positioned adjacent existing construct 12.In the arrangement shown, slot 20 f is arranged to face the additionalspinal implant 26 to be implanted and extends axially fully through boththe proximal end 20 b and the distal end 20 c. Slot 20 f is sized andconfigured to receive therethrough the rod connector introducer 21 andthe connecting portion 70 of rod connector 22 with the elongateadditional rod 24 projecting therefrom. Slot 20 g is formeddiametrically opposite slot 20 f, as shown in FIG. 14, slot 20 gextending through distal end 20 c and extending axially throughperimetric sidewall 20 d for a length that extends outside skin S of thepatient. Slot 20 g is sized and configured to receive therethrough atleast a portion of the rod connector 22 and rod connector introducer 21to accommodate rotation of the rod connector introducer 21, as will bedescribed. A bracket 138 may be utilized to fix the access port 20 to anoperating table in a conventional manner so as to maintain the accessport 20 in place throughout the surgical procedure. While access port 20is described in this arrangement as being generally tubular, it shouldbe appreciated that access port may include other suitable structuressuch as by a pair of opposed blades defining a lumen therebetween,wherein the blades may be coupled at their proximal ends by a suitablering or other coupling member.

Having described the devices and instruments for extending an existingspinal rod construct in a patient, the procedures for such extension arenow described with particular reference to FIGS. 15-23. The firstprocedure relates to percutaneously extending an existing spinalconstruct 12 as shown in FIG. 15 with an inline ipsilateral additionalconstruct 14 as described above. The engagement of the additional spinalimplant 26 as a component of the additional spinal rod construct 14 isdescribed. Spinal implant extension assembly 18 comprises an elongateextension 28 which includes a hollow sleeve 140 releasably secured tothe additional spinal implant 26. Spinal implant 26 is described asnoted above with reference to FIG. 2 as being a polyaxial pedicle screwin this arrangement. Sleeve 140 has a pair of opposing slots 142extending axially through the sleeve diametrically apart. The slots 142are aligned and in communication with the slot 62 in the upper yokeportion 58 (see FIG. 2) of the spinal implant 26. The additional spinalimplant 26 is percutaneously attached to the pedicle of the third spinalsegment 60, which may be a segment of the sacrum S1 or another vertebralbody. Additional spinal implant 26 is introduced through a smallpercutaneous incision 144 made through the skin S of the patient. Theincision 144 is approximately 10-30 mm in length. The dilation ofincision 144 and the percutaneous attachment of spinal implant 26 to aspinal segment such as vertebral body 60 is fully described in commonlyassigned U.S. patent application Ser. No. 12/818,965, entitled “Systemfor Percutaneously Fixing a Connecting Rod to a Spine”, filed on Jun.18, 2010, and issued as U.S. Pat. No. 8,142,437, (the '437 Patent), thedisclosure of which is incorporated herein by reference in its entirety.Once spinal implant 26 is attached to the vertebral body 60, the sleeve140 as well as slots 142 project out from the patient through dilatedincision 144 with the slots 142 being rotatably manipulable uponrotation of sleeve 140 to be aligned with slot 20 f of access port 20 aswill be described with reference to FIG. 16.

Using fluoroscopy or other suitable imaging techniques, the existingspinal rod 42 is initially targeted so as to establish the position ofthe existing rod 42 in the patient. In this instance, theinterconnecting portion 42 a of existing rod 42 is targeted rather thanextending portion 42 b projecting outwardly beyond implant 34. A smallpercutaneous incision 146 is made through the skin S of the patient, theincision 146 being approximately 10-30 mm in length, although othersuitable dimensions may be used. A targeting rod 148 is placed throughthe incised puncture and pushed through the tissue of the patient downto the existing spinal rod 42. Once the access path has been created andthe position of the existing rod 42 established a series of sequentiallyincreasing dilating instruments are inserted over the targeting rod 148.As depicted in FIG. 16, the dilating instruments include dilatingcannulas 150, 152 and 154 of increasing diameter. The number of dilatingcannulas may vary depending upon the procedure and the desired extentthe incision 146 is to be expanded upon dilation. In addition, thedilating cannulas may include features that maintain the lateralposition of such cannulas relative to existing rod 42 during insertion.Access port 20 is then finally placed over the last dilating cannula 154with the opposing slots 20 f and 20 g communicating with existing rod 42such that the distal end 20 c of access port 20 straddles but does notattach to existing rod 42, as shown in FIG. 16. The dilating instrumentsare then removed as illustrated in FIG. 17 leaving the access port 20 inplace. The central longitudinal axis of the access port 20 is generallyaligned with and perpendicular to the longitudinal axis of existing rod40. Bracket 138 may be utilized to fix the access port 20 to theoperating table so as to maintain access port 20 fixed in placethroughout the surgical procedure. The proximal end 20 b of the accessport 20 as well as slot 20 f project out from the patient's skin, S,with access port slot 20 f being generally aligned with and in facingrelation to slots 142 of sleeve 140 in spinal implant extension assembly18. Although also shown as extending outwardly of the patient's skin, S,slot 20 g may be of length to lie below the patient's skin, S.

By reference to FIG. 18 as well as to FIG. 1, the introduction of therod connector 22 through manipulation of the rod connector extensionassembly 16 is explained. The handle 118 may be in the 45° position forthis stage of the procedure. With access port 20 fixed in place asurgeon grasps handle 118 and initially orients the extension 30 of rodconnector introducer 21 generally parallel to the spine of the patientsuch that the axis 24 b elongate additional rod 24 is oriented in afirst position generally parallel to the longitudinal axis of accessport 20. In this position, the additional rod 24 is within the lumen 20e of access port 20 with the connecting portion 70 of rod connector 22extending through and projecting outwardly from slot 20 f of access port20. Through manipulation of rod connector introducer 21 the additionalrod 24 is moved in this first orientation until the rod connector 22 isbelow the skin S of the patient. At this point, the rod connectorintroducer 21, with the access port slot 20 f serving as a guide, isrotated so that additional rod 24 is rotated clockwise as viewed in FIG.19 in a direction indicated by arrow, R. from its first orientation outfrom access slot 20 f and toward sleeve 140 of spinal implant extensionassembly 18. During such movement, the distal end 24 a of additional rod24 is subcutaneously moved through tissue of the patient beneath theskin S of the patient toward the sleeve 140 of spinal implant extensionassembly 18.

Continued rotation of handle 118 in the direction R further rotates rodconnector introducer 21 until the distal end 24 a of additional rod 24approximates sleeve 140. With fluoroscopy the distal end 24 a ofadditional rod 24 is guided into slot 142 that is in facing relationshipwith access port slot 20 f, as shown in FIG. 20 for ultimate reductioninto slot 62 of additional spinal implant 26. It should be appreciatedthat the additional rod distal end 24 a may be directly received withinslot 62 of additional spinal implant 26. During this portion of therotation of rod connector introducer 21, the rod connector 22 as well asthe distal end 124 b of the rod connector introducer extension 30 mayproject outwardly from the opposite access port slot 20 g to accommodatethe rotation of rod connector introducer 21.

Upon final rotation of rod connector introducer 21 by handle 118 asshown in FIG. 21 the distal end 24 a of additional rod 24 extendsthrough both slots 142 of sleeve 140 and is either situated in slot 62of additional spinal implant 26(FIG. 2) or closely thereto. In thisposition the additional rod 24 has been moved to a second differentorientation such that the axis 24 b is transverse, and substantiallyperpendicular, to the longitudinal axis of access port 20. Also with theaid of fluoroscopy, the rod connector 22 at this point receives theexisting spinal rod 42 within the opening 78 between hooks 74 and 76 ofrod connector first portion 66. As described above, with first portion66 capable of articulating while being held against rotation by the hookrotator 136, proper receipt of existing spinal rod 42 within opening 78is achieved even if the longitudinal axis of rod connector introducer 21is not precisely perpendicular to the axis of existing rod 42 thusallowing for potential irregularities of the spine. In this position,existing spinal rod 42 is in an unlocked position with respect to rodconnector 22. Prior to rotation of rod connector hooks 74 and 76 toengage existing rod 42 for locking, the surgeon may, if necessary,reduce the additional rod 24 into slot 62 of additional spinal implant26. Such reduction may be achieved by connecting a rod persuader (notshown) to a rod persuader coupling member 156 disposed at the proximaland of sleeve 140. The rod persuader including its structure andcooperation with rod persuader coupling member 156 is fully described inthe '437 Patent, the disclosure of which is incorporated herein byreference in its entirety.

With continued reference to FIG. 21 as well as to FIGS. 5-6, theengagement of the rod connector 22 to the existing spinal rod 42 isdescribed. Hand wrench 135 is used to suitably depress ring 136 g forattachment to tool attachment surface 136 d as described above and isrotated either by hand or an appropriate tool. Rotation of wrench 135rotates hook rotator shaft 136 a as well as engagement surface 136 ewhich is engaged within socket 104 b of rotation pin 104. Upon suchrotation of the shaft 136 a, the rotation pin 104 rotates the firstportion 66 of the rod connector 22 about the axis of engagement 100 in amanner to facilitate alignment of opening 78 relative to existing rod42. Hooks 74 and 76 and the respective rod engagement member 74 a and 76a are then rotated in a manner to engage the existing rod 42. As thehooks 74 and 76 are rotated, the engagement surface 108 a at the distalend of rotation element 102 engages the existing rod 42 under the biasof wave spring 106 pushing the head 104 a of the rotation pin 104slightly upwardly into opening 97 of first portion 66. During suchrotation the existing rod 42 is thereby received between the rodengagement member 74 a and 76 a and rotation pin engagement surface 108a in a snap-fitting movement that provides a tactile and potentially anaudio indication to the surgeon that the existing rod 42 is properlyseated in the rod connector 22 in a provisional engagement whereby therod connector 22 is held on but not locked to the existing rod 42. Rodconnector first portion 66 is rotated approximately 60° with respect tosecond portion 68 to establish such provisional engagement. It should beunderstood that first portion 66 may be rotated relative to secondportion 68 at other angles which may be less than 60° or up toapproximately 90°.

Once the rod connector 22 has been rotated to the provisional engagementposition, the distal end 24 a of additional rod 24 may then be securedto additional spinal implant 26 as described with reference to FIG. 22.Set screw 64 is suitably attached to a driver instrument 158 and sizedand configured to introduce the set screw 64 with instrument 158attached thereto into and through hollow sleeve 140 until set screw 64engages the threads in the slot 62 of the upper yoke portion 58. Setscrew 64 is tightened by rotation of instrument 158 to secure theadditional rod 24 to the additional spinal implant 26. Instrument 158 isthen detached from set screw 64 and removed from sleeve 140.

Turning now to FIG. 23 as well as to FIGS. 5-6 and 11, locking of therod connector 22 to additional rod 42 is described. After removing hookrotator 136 and inner sleeve 134 from rod connector introducer 21, setscrew 116 is suitably attached to a driver tool 160 with the distal tipof tool 160 in engagement with socket 116 b of set screw 116. Tool 160with set screw 116 attached thereto is sized and configured to bereceived within lumen 124 c of outer sleeve 124 of rod connectorintroducer 21 until set screw 116 engages the threads 98 in rodconnector second portion 68. As noted above, the lower distal surface116 c of set screw 116 engages the upper surface of head 104 a ofrotation pin 104 during rotational insertion of set screw 116. Continuedinsertion and tightening of the set screw 116 into threads 98 will pushthe rotation pin 104 downwardly causing the rod engagement surface 108 aat the lower end of the rotation element 102 to forcibly engage theexisting rod 42. The force against the existing rod 42 also causes thefirst portion 66 and thereby the ball insert 80 to move downwardlyrelative to second portion 68 forcing the outer spherical surface 82 ofball insert 80 tightly against interior spherical surface of socket 86of second portion 68, thereby locking first portion 66 and secondportion 68 securely together.

With rod connector 22 properly secured to existing spinal rod 42, tool160 is detached from set screw 116 and removed from rod connectorintroducer 21. Spinal implant extension assembly 18, rod connectorintroducer 21 and access port 20 are also then removed from the patient.To facilitate removal of rod connector introducer 21 from rod connector22, handle 118 may be adjustably moved to a position generally parallelto the longitudinal axis of outer sleeve 124 as shown, for example inFIG. 9. With the removal of the instruments the inline ipsilateralextension of the existing spinal construct 12 by additional spinalconstruct 14 as shown in FIG. 2 is complete and the incisions 144 and146 maybe appropriately sutured. In the percutaneous proceduredescribed, the rod connector 22 is inserted through the access port 20and rotated for attachment to the existing rod 42 in a top loadingprocedure without disturbing the existing implants 34 and 36 or theprevious connections to the existing rod 42. Such top loading allows asurgeon to insert the rod connector 22 by manipulating the rod connectorby rotation and connect it to the existing rod 42 from above the spinefacilitating the percutaneous procedure.

In the procedure just described, rod connector 22 is attached toexisting spinal rod 42 by targeting the interconnecting extent 42 abetween two existing bone engaging implants 34 and 36, each of which isengaged respectively to a corresponding vertebra 38 and 40. The elongateadditional rod 24 projecting from rod connector 22 may be attached toadditional spinal implant 26 in either the caudal or cephalad direction.Using the same technique described herein, it should be understood thatrod connector 22 may also be used to attach an existing spinal constructto other bony segments, not only within the spine, such as vertebralbodies or the sacrum, but outside the spine, such as the ilium. Such anarrangement is contemplated, for example as shown in FIG. 24 where boneengaging implant 36 is attached to vertebral body L5 and bone engagingimplant 34 is attached to segment S1 of the sacrum and these implantsare interconnected by existing spinal rod 42 with extending portion 42 bprojecting in the caudal direction. With extending portion 42 b havingsufficient extent, extending portion 42 b may be targeted for receipt ofand connection to rod connector 22, as described above. A third boneengaging implant 162 such as an iliac screw similar to spinal implant 26may be percutaneously secured to the ilium through a separate spacedincision with a releasable bone implant extension assembly similar tospinal implant extension assembly 18, as described in the '437 Patent.Rod connector 22 may then be inserted with additional rod 24 passedsubcutaneously from existing rod 42 to the iliac screw 162 in a manneras described hereinabove to form the additional construct extending fromsegment S1 of the sacrum to the ilium. Rod connector 22 may beconfigured with or without jog 72 and curved if desired to accommodatethe anatomical conditions.

Having described a particular arrangement of rod connector 22 whereinadditional rod 24 is integrally attached thereto, two alternativearrangements are described wherein a rod connector is configured toreceive an additional rod rather than such additional rod beingintegrally attached. The first alternative arrangement is shown anddescribed with reference to FIGS. 25 and 26. Rod connector 200 comprisesa first portion 66 articulatingly attached to a second portion 68, firstportion 66 and second portion 68 having structure identical to first andsecond portions 66 and 68 respectively of rod connector 22. Rodconnector 200 further includes a connecting portion 202 projectingoutwardly from second portion 68 and terminating in an additional rodsupport 204. Support 204 comprises a yoke 206 having a pair of opposingupstanding arms 206 a and 206 b defining an open ended slot 208 havinginternal threads 210. The slot 208 is sized and configured to receiveand support therein an additional spinal rod 212 which is fastened tothe yoke 206 by a set screw 214 or other suitable fastener. As shown inFIG. 26, rod connector 200 is configured to be attached to the existingspinal rod, such as rod 42 and to receive and support additional rod 212in an orientation that may be generally parallel to existing rod 42. Assuch, the axis of additional rod 212 is laterally offset with respect tothe axis of existing rod 42. It should be appreciated that dependingupon the anatomy of the patient the orientation of the additional rod212 relative to the existing rod 42 may not necessarily be parallel.

By reference to FIGS. 27 and 28 a minimally invasive technique forattaching rod connector 200 to a spinal rod in an existing spinalconstruct is described. A rod connector introducer 21 as described abovemay be releasably attached to second portion 68 of rod connector 200. Anelongate extension 28 as described above with respect to spinal implantextension assembly 18 includes a hollow sleeve 140 that is releasablysecured to the additional rod support 204 in the same manner as attachedto additional spinal implant 26. To attach rod connector 200 to existingspinal rod such as rod 42, either the interconnecting portion 42 abetween two existing bone implants or the extending portion 42 bprojecting beyond one of the two existing bone implants may be targetedfor attachment. FIG. 28 illustrates the targeting of the interconnectingportion 42 a for connection. Using fluoroscopy or other suitable imagingtechniques as described above, a small incision 216 is initially formedthrough the skin S. The incision 216 is enlarged radially and laterallywith a series of sequentially increasing dilating instruments with theultimate insertion of an oval access port 218. Oval access port 218 issized and configured to receive the assembly 220 comprising rodconnector 200, rod connector introducer 21 and the elongate extension28. A hook rotator, such as hook rotator 136, may be inserted throughrod connector introducer 21 to engage the rotation element 104 in rodconnector 200 so as to restrain the hooks 74 and 76 from rotation, asset forth above. The assembly 220 is introduced into oval access port216 with the rod connector 200 in an orientation that is maintainedbeneath the skin until the interconnecting portion 42 a of existingspinal rod 42 is received within the opening 78 between hooks 74 and 76,as described above. Rotation of the hooks 74 and 76 about axis ofengagement 100 and connection of the rod connector 200 to theinterconnecting portion 42 a of existing rod 42 proceeds thereafter asdescribed above.

In the attachment of rod connector 200 by the procedure shown in FIG.28, the yoke 206 and therefore the additional rod 212 are locatedlaterally farther away from the midline of the patient than the existingspinal rod 42. In a variation, the rod connector 200 may be attachedwith the yoke 206 located interiorly of the existing spinal construct 12such that the additional rod 212 lies closer to the midline of thepatient. Once the rod connector 200 is properly secured to the existingrod 42, the rod connector introducer 21 with the hook rotator 136 andaccess port 218 are removed and the elongate extension 28 is maintained.A third bone engaging implant such as an iliac screw similar to spinalimplant 162 in FIG. 24 may be percutaneously secured to the iliumthrough a separate spaced incision with a releasable bone implantextension assembly similar to spinal implant extension assembly 18, asdescribed in the '437 Patent. An additional rod may now be used topercutaneously interconnect yoke 206 of rod connector 200 with the thirdbone engaging implant by passing the additional rod subcutaneouslybeneath the skin of the patient using the extensions attached to yoke206 and the third bone implant as guides in a manner as fully describedin the '437 Patent. It should be appreciated that an additional rod mayalso be percutaneously placed between the yoke 206 of rod connector 200and other bony segments within the spine, such as vertebral bodies orthe sacrum, either in a caudal or cephalad direction.

Turning now to FIGS. 29 and 30 the second alternative arrangement isshown and described. Rod connector 300 comprises a first portion 66articulatingly attached to a second portion 68, first portion 66 andsecond portion 68 having structure identical to first and secondportions 66 and 68 respectively of rod connector 22. Rod connector 300further includes a connecting portion 302 projecting outwardly fromsecond portion 68 and terminating in an additional rod support 304.Support 304 comprises a yoke 306 having a pair of opposing upstandingarms 306 a and 306 b defining an open ended slot 308 having internalthreads 310. The slot 308 is sized and configured to receive and supporttherein an additional spinal rod 312 which is fastened to the yoke 306by a set screw 314 or other suitable fastener. As shown in FIG. 30, rodconnector 300 is configured to be attached to the existing spinal rod,such as rod 42 and to receive and support additional rod 312 in anorientation generally inline with existing rod 42. As such, the axis ofadditional rod 312 is generally parallel to and colinear with the axisof existing rod 42. Such an arrangement is contemplated where anexisting spinal construct exists, for example, between bone implantsattached to vertebral bodies L4 and L5 and extension is desiredgenerally inline to sacral segment, S1 in the caudad direction or tovertebral body L3 in the opposite cephalad direction. In either case,the extending portion 42 b of the existing rod 42 is targeted forconnection by the rod connector 300. It should be appreciated thatdepending upon the anatomy of the patient the orientation of theadditional rod 312 relative to the existing rod 42 may not necessarilybe precisely inline and colinear.

To attach rod connector 300 to existing spinal rod such as rod 42 thatinterconnects two existing bone engaging implants, the extending portion42 b projecting beyond one of the two existing bone implants istargeted. The attachment of rod connector 300 through an oval accessport such as access port 218 within dilated incision similar to incision216, proceeds in a similar manner as described with respect to rodconnector 200. A third bone engaging implant such as a pedicle screwsimilar to spinal implant 26, may be percutaneously secured to thesacrum or additional vertebral body through a separate spaced incisionapproximately 10-30 mm in length with a releasable bone implantextension assembly similar to spinal implant extension assembly 18, asdescribed in the '437 Patent. An additional rod may now be used topercutaneously interconnect yoke 306 of rod connector 300 with the thirdbone engaging implant by passing the additional rod subcutaneouslybeneath the skin of the patient using the extensions attached to yoke306 and the third bone implant as guides in a manner as fully describedin the '437 Patent.

While the existing spinal construct 12 has been described herein asbeing extended by a single level, it should be appreciated that theextension may comprise two or more levels with the devices andinstruments as described herein. In addition, while the devices andinstruments described herein provide surgeons the ability to extendexisting spinal constructs at least minimally invasively and morepreferably, percutaneously, it should be understood that a surgeon mayalso use the described devices and instruments in an open procedure ifthat is the surgeon's surgical preference.

While the invention has been illustrated and described in detail in thedrawings and foregoing description, the same should be considered asillustrative and not restrictive in character. It is understood thatonly the preferred embodiments have been presented and that all changes,modifications and further applications that come within the spirit ofthe invention are desired to be protected.

What is claimed is:
 1. A method of percutaneously attaching anadditional rod to an existing spinal construct implanted in a patienthaving at least two bone engaging implants engaged to correspondingspinal segments and interconnected by an existing spinal rod, comprisingthe steps of: making a first incision through the skin of a patient toaccess a third bony segment; percutaneously introducing a third boneengaging implant through said first incision and attaching said thirdbone engaging implant to said third bony segment; making a secondseparate incision through the skin of said patient; accessing throughsaid second separate incision only a section of said existing spinal rodbetween two bone engaging implants; percutaneously introducing a rodconnector through said second incision, said rod connector including afirst portion defining an axis and having a rod receiving opening forreceipt of said section of said existing spinal rod, and a secondportion having an opening therethrough and attached to said firstportion, said second portion including an elongate additional rod havinga free distal end projecting therefrom; subcutaneously moving saidelongate additional rod between said first incision and said secondincision while moving said first portion of said rod connector adjacentto said section of said existing spinal rod.
 2. The method of claim 1,wherein said step of accessing only said section of said existing rodincludes the step of targeting the existing spinal rod to establish theposition of said existing rod in said patient using a targeting rod withimaging techniques to determine the position of said existing spinal. 3.The method of claim 2, wherein said section of said existing spinal rodcomprises an interconnecting portion between two bone engaging implants,and wherein said targeting step includes targeting said interconnectingportion.
 4. The method of claim 3, wherein said accessing step includesthe step of placing said targeting rod through said second incision andextending said targeting rod down to said interconnecting portion. 5.The method of claim 4, further including the step of expanding saidsecond incision by placing over said targeting rod a series ofsequentially increasing dilating instruments.
 6. The method of claim 5,including the step of placing an elongate access port over the lastplaced dilating instrument, the access port having a distal end and aproximal end and a length extending therebetween, said access portdefining a lumen extending therethrough, the distal end being placedadjacent said interconnecting portion of said existing spinal rod withsaid proximal end projecting outwardly from the skin of said patient. 7.The method of claim 6, wherein said step of percutaneously introducingsaid rod connector includes inserting said rod connector through saidaccess port and engaging said first portion of said rod connector withsaid interconnecting portion.
 8. The method of claim 1, wherein saidfirst portion has in communication with said rod receiving opening a rodengagement member rotatable relative to said second portion forengagement with said section of said existing spinal rod.
 9. The methodof claim 1, wherein said free distal end of said additional rod of saidrod connector is inserted into said second incision prior to said firstportion in a first angular orientation relative to said existing spinalrod until below the skin of said patient and moved subcutaneously to adifferent second orientation below the skin.
 10. The method of claim 9,wherein said additional rod is moved to said second orientation byrotating said rod connector relative to and toward said existing rod.11. The method of claim 10, wherein said rod connector is percutaneouslyintroduced in a top-loading procedure without disturbing said existingspinal construct.
 12. A method of percutaneously attaching an additionalrod to an existing spinal construct implanted in a patient having atleast two bone engaging implants engaged to corresponding spinalsegments and interconnected by an existing spinal rod, comprising thesteps of: providing a rod connector comprising a first portion and asecond portion, said first portion defining a rod receiving opening forreceiving said existing spinal rod, said second portion including aconnecting portion defining an elongate additional rod projectingtherefrom and terminating in a free distal end; making an incisionthrough the skin of said patient to access only a section of saidexisting spinal rod between two bone engaging implants; introducing saidrod connector into said incision in a first orientation until the freedistal end of said additional rod extends below the skin of saidpatient; moving said rod connector to a second orientation during whichmovement said free distal end of said additional rod is movedsubcutaneously below the skin of said patient and said rod receivingopening of said first portion is placed onto said section of saidexisting spinal rod; and securing said rod connector to said section ofsaid existing spinal rod.
 13. The method of claim 12, wherein saidsecond portion is attached to said first portion in a first unlockedposition in which said second portion is rotatable relative to saidfirst portion, and in a second locked position in which said secondportion is fixed relative to said first portion.
 14. The method of claim13, wherein said second portion is locked to said first portion in saidsecond locked position in a single operation with the securement of saidrod connector to said section of said existing spinal rod.
 15. Themethod of claim 14, further including the steps of: making anotherincision through the skin of said patient separate from said incision;and percutaneously engaging an additional bone engaging implant to anadditional bony segment.
 16. The method of claim 15, wherein saidadditional implant has a slot, and wherein the distal free end of saidadditional rod is moved subcutaneously through said tissue of saidpatient and into the slot of said additional implant.
 17. A method ofpercutaneously extending an existing spinal construct implanted in apatient having at least two bone engaging implants engaged tocorresponding spinal segments and interconnected ipsilaterally by anexisting spinal rod, comprising the steps of: providing a rod connectorcomprising a first portion, a second portion, and an additional rodprojecting from and integral with said second portion, said additionalrod terminating in distal free end; percutaneously creating an accesspath to only a section of said existing spinal rod; attaching said firstportion of said rod connector to said section of said existing spinalrod through said access path; percutaneously engaging an additional boneengaging implant to an additional bony segment through a path separatefrom said access path; subcutaneously placing said additional rodbetween said section of said existing spinal rod and said additionalimplant; securing said free distal end of said additional rod to saidadditional implant through said separate access path; and securing saidfirst portion of said rod connector to said section of said existingspinal rod through said access path.
 18. The method of claim 17, whereinsaid second portion of said rod connector has an opening therethrough.19. The method of claim 18, wherein said second portion is attached tosaid first portion in a first unlocked position in which said secondportion rotates relative to said first portion, and in a second lockedposition in which said second portion is fixed relative to said firstportion.
 20. The method of claim 19, wherein said second portion of saidrod connector is locked to said first portion of said rod connectorthrough said opening through said second portion.
 21. The method ofclaim 20, wherein said second portion of said rod connector is locked tosaid first portion of said rod connector in the same step as said firstportion of said rod connector is secured to said section of saidexisting spinal rod.
 22. The method of claim 21, wherein an elongateextension is releasably attached to said additional implant, and whereinsaid additional implant is engaged with said additional bony segment bymanipulation of said elongate extension through said separate path.